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The selected case design required multiple data sources to critically explore the current curriculum which did not seem to fit the needs and requirements of the health education context. Various approaches to investigate the quality of the course, its usefulness for practice and to obtain relevant information were employed. A Delphi technique was used to obtain consensus on the competencies and content areas needed for the anaesthetic and recovery room component of the relevant programme.

4.2.1. Research approach, design and research paradigm

The study approach (cf. sect. 4.2.1.1), study design (cf. sect. 4.2.1.2) and study paradigm (cf. sect. 4.2.1.3) are discussed in the following sections.

4.2.1.1. Research approach

An inductive approach through an interpretivist lens of knowledge production was used. An interpretivist knowledge view stems from the hermeneutic philosophy which refers to the art and philosophy of interpreting the meaning of a unit of information (Mackenzie & Knipe, 2006:5; Polit & Beck, 2012:496). Researchers who take an interpretive view seek to understand the whole of a unit in terms of its parts and the parts in terms of the whole. Hence, such inquiries primarily rely on qualitative data generated from research participants who have directly experienced the construct or phenomenon under investigation and mainly capture ‘insider’ knowledge (Henning, 2004:20; Polit & Beck, 2012:496). The focus in this case was therefore on the experiences, views, perceptions and expressed needs of participants based on their professional involvement and roles in an everyday working environment (Creswell, 2009:8; Henning, 2004:20).

4.2.1.2. Research design

A programmatic case study design was chosen to connect the research question, steps and data within this research project (Archer, 2016:88; Polit & Beck, 2012:741). Depending on the philosophical assumptions of the researcher, case studies might originate from a critical, interpretivist or positivist stance (Maree, 2007:5). From an interpretivist perspective (cf. sect. 4.2.1.3) case study research strives towards a holistic

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understanding of the case being studied from an insider’s point of view (Brink, Van der Walt & Van Rensburg, 2012:25); in this research the case being the anaesthetic and recovery room course as received and experienced by the relevant stakeholders (the insider’s point of view).

Different researchers define and describe case study designs differently, depending on their views and points of departure (Hancock & Algozzine, 2006:9-11; Polit & Beck 2012:271; Salkind, 2010:2; Stake, 1995:xi). According to Yin (2014:16), a case study is “an empirical inquiry that investigates a contemporary (the “case”) in depth and within its real-world context, especially when the boundaries between phenomenon and context may not be clearly evident”. Yin’s (2014) definition illustrates the contextual nature of case studies (Meyer, 2001:330) and advocates it as a legitimate research design within a real-world context (Yazan, 2015:138). Hence, the case study design, which relies on multiple data sources (Yin, 2012:5; Yin, 2014:17 & 24), has been effectively used in many studies in several disciplines, e.g., economics, sociology, medicine, law, nursing, social work and education due to its versatile approach where various data collection methods are needed (Keeney et al., 2011:3; Salkind, 2010:4 & 7).

The named design was elected to understand whether the current curriculum adequately prepared students for their role as A/RRAs as there were calls for competent graduates to assist anaesthetists and RNs in the operating department. It was seen as an inquiry strategy which the researcher could use to explore the study component within contemporary healthcare curricula (Archer, 2016:88; Creswell, 2009:13). This corresponds with Meyer’s (2001:330) view that a case study is useful to respond to questions relating to contemporary healthcare curricula and does not limit the researcher to one data technique (Gerring, 2007:10). Consequently, quantitative and qualitative techniques were employed in this case to generate and analyse evidence from a real-life context (Meyer, 2001:330).

Other research designs such as experiments, surveys, action research, grounded theory and archival research were not suitable for this study. These designs are not capable of exploring particular programmatic cases which a researcher might be interested in (Yazan, 2015:138). Experiments and surveys fall within a positivist domain and thus would have undermined the purpose and objective of the current study (Baker, 2001 cited in Ihuah & Eaton, 2013:939; Polit & Beck, 2012:12-15). An action research design was also not an option as such research expects the researcher to change the attitude and behaviour of the study participants which were not in line with the purpose of this study (Ihuah & Eaton, 2013:939). The researcher of this current study is situated within the PHEI and is the manager of higher education and training. The participants could have felt intimidated and said what they believed the researcher wanted them to say, which would not have delivered the desired results. The empirical study would not have been ethically justifiable. A grounded theory or an archival research design was also not appropriate. The former allows for data to be collected without an initial theoretical framework and testing the data before a conclusion is made (Creswell, 2009:27; Ihuah & Eaton, 2013:939) whereas the latter only focuses on the past and is limited by data held in the archive. By focusing only on archival data or current curriculum documents it would have distracted the current researcher from the purpose, question and objectives of this study (Ihuah & Eaton, 2013:939).

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Hence, the programmatic case study design offered exploratory opportunities to address the research question (cf. Ch. 1, sect. 1.5) and was thus preferred (Yin, 2012:5; Yin, 2014:238). However, one weakness of a case study design is that there are no recipes that guide case study research. But, Yin (2014:24-29) and Meyer (2001:329) provide useful insights and recommendations on its use. The design and data collection methods were tailored to suit the research questions in a principled way. Also, as suggested by Yin (2014:29), the researcher started with the main research and subsidiary questions (cf. Ch. 1, sect 1.5) as it provided a firm guide to follow in the rest of the research process. The four steps, as suggested by Yin (2014:29), were used to plan and execute this study in combination with the six-step approach of Neale et al. (2006:5-6) (cf. Fig. 4.1) of which the main research question constituted the first step. Next, the subsidiary questions, which constituted the objectives of the study, were developed to: (1) establish how the stakeholders currently experience operating department assistants (ODAs) in the anaesthetic and recovery room practice; (2) establish whether the current cognitive, affective and psychomotor skills of ODAs are sufficient to perform their anaesthetic and recovery room duties; (3) establish whether there is a hierarchy of importance regarding the sequencing of cognitive, affective and psychomotor skills of ODAs; (4) establish the possible gaps in the cognitive, affective and psychomotor skills currently taught to ODAs and (5) establish what a needs-based curriculum for anaesthetic and recovery room practice in an ODA programme would entail. The third step was to identify the ‘study unit’ (‘the case’) – which was the anaesthetic and recovery room component – within a broader ODA education and training programme offered at a particular private higher education provider in SA. Then the data generation methods and ways to logically link the data to the aims of the study were determined. The final step was to determine the criteria for interpreting the data (Yin, 2014:29). These last two steps are very similar to the six-step inquiry of Neale et al. (2006:5-6).

Figure 4.1: Programmatic case study steps (adapted from Neale et al., 2006:5-6)

Together with Yin’s (2014:29) logical steps, the step-by-step approach of Neale et al. (2006:5-6) were employed to plan and execute the data collection process (cf. Fig 4.1). Although the researcher chose a single programmatic case study design for its in-depth and rich knowledge (Keeney et al., 2011:1; Mackenzie & Knipe, 2006:938; Polit & Beck, 2012:504; Yin, 2012:5), it introduced a range of strategic, ethical and personal issues into the research (Creswell, 2009:177) which the researcher had to be aware of. Thus,

1. PLAN

- Identified stakeholders - Identified information needed

and from whom

- Identified documents for review 2. DEVELOP DATA COLLECTION INSTRUMENTS - Semi-structured interview guides - Written questionnaires 4. COLLECT DATA - Gathered all documents - Set up interviews &obtained

consent

- Conducted interviews/ completed questionnaire

5. ANALYSE DATA - According to Miles and

Huberman’s (1994:92) analytical abstraction ladder

3. TRAIN DATA

COLLECTOR

- Identified and trained one data collector

6. COMMUNICATE DATA - Compiled a Delphi

questionnaire

- Solicited feedback

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precautionary methods such as bracketing were introduced to prevent ethical drift and bias. As the researcher was involved in the development of the current ODA curriculum, she was constantly aware of and alerted to possible bias as a training manager (cf. sect. 4.3).

One concern related to case studies is its generalisability (Polit & Beck, 2012:504). Yin (2014:21) points out that case studies might not be generalisable to populations but to theoretical propositions. A more detailed discussion is presented in the next section.

Generalisation in case study research

Generalisation, also known as transferability (Archer, 2016:89), is defined by Stake (2010:219) as “applying a statement to all or many cases”. Smaling (2003:2-3) supports Firestone’s (1993:16) stance of statistical and analytical generalisation as well as case-to-case transfer as forms of generalisation which can be used in research studies which use mainly qualitative data. However, even these forms of generalisation are not always applicable to all situations and, if it is, it is hard, if not impossible, to generalise findings from qualitative data to other settings (Firestone, 1993:16). Plowright (2011:31) has the same view and proposes it is problematic to generalise the findings from case studies because of the uniqueness of each case study. Firestone (1993:16-17) states a case study researcher might consider analytical generalisation, but any extrapolation of sample-to-population is unlikely. Case-to-case transfer can be helpful, but only occurs when a programme from one setting is adopted or adapted by the researcher from another setting. However, Smaling (2003:2) points out case studies do not need to be generalisable, but the researcher has an obligation to provide rich, detailed and thick descriptions of data concerning the chosen case to enable readers and other researchers to judge and utilise the findings in their own research as well as helping them to bridge the gap between possible application settings (Firestone, 1993:18). According to Firestone (1993:19), the burden to see possibilities for transferability lies with the reader and not the researcher. The researcher’s responsibility stops when he or she has provided and analysed the relevant data.

4.2.1.3. Research paradigm

This study mainly embraced an interpretivist knowledge lens by acknowledging that multiple realities have manifold meanings within a social context and findings are researcher-dependent (Denzin & Lincoln, 2018:344; Yazan, 2015:139; Yin, 2014:17). An interpretative paradigm is often set in motion by inquiry strategies which connect the researcher with data collection and methods of analysis. Interviews and document analysis are two such methods which a case study relies on (Denzin & Lincoln, 2018:21). The interpretivist combines a realist / relativist ontology (nature of the reality), a subjectivist epistemology (relationship between the known and the researcher), a naturalistic set of methodological procedures (how the knowledge is gained within a natural world) and a balanced axiology (ethical issues to be considered when planning the research) (Bitzer, 2018:14; Denzin & Lincoln, 2018:19-20 & 98). According to Yin (2014:17) much of case study research is usually oriented towards a realist perspective but could advance towards a relativist perspective. The latter acknowledge “multiple realities having multiple meanings…” (Yin, 2014:17). A brief discussion on why an interpretivist paradigm suited this study follows.

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The current case study focused on a competency-based ODA curriculum framework, which had to meet the needs of different stakeholders. The researcher assumed that the social interactions in the classroom and workplace (operating department) could be explored though a variety of, predominantly interviews (researcher-participant interactions) and group interviews (participant-participant interactions), methods to endeavour to understand the topic being researched from the participants’ (managers, anaesthetists, ODAs, students and educators) viewpoint (Bitzer, 2018:14). Conducting open-ended individual and group interviews dealing with the reality of the ODA programme within the PHEI and the hospitals (relativist ontology), and interpreting the data based on the participants’ views of the studied situation thus played a key role in the study (Creswell, 2009:8; Ihuah & Eaton, 2013:935-940). The researcher wanted to gain an improved understanding, from the different participants’ perspectives, of the knowledge, skills and attitudes ODAs require to function in the anaesthetic and recovery room environment. The study thus draws heavily on inductive reasoning from qualitative data. Analysing the qualitative data was a recursive process to systematically review the data as a means to understand the topic being investigated (Hancock & Algozzine, 2006:56-57; Salkind, 2010:8). The main focus was on interpreting and analysing the data generated by the participants (Denzin & Lincoln, 2018:20; Gill, Stewart, Treasure & Chadwick, 2008:291; Mackenzie & Knipe, 2006:3; Polit & Beck, 2012:264) to develop trends and meaning (subjectivist epistemology) (Creswell, 2009:8-9; Denzin & Lincoln, 2018:98) through cognitive processes and the researcher’s own thinking. The study findings reflect the values and balanced view of the researcher (Bitzer, 2018:14).

Although the study was mainly based on qualitative data, questionnaire data were employed to inform, enhance and expand the qualitative findings. Using closed-ended questions, presented by the researcher, consumed a realist orientation (Yin, 2014:220).

The rationale behind the choice of an interpretive knowledge lens was the nature of the posed research questions (Plowright, 2011:8 & 15; Yin, 2014:29). The study mainly involved qualitative data (Creswell, 2009:11; Ihuah & Eaton, 2013:938; Mackenzie & Knipe, 2006:6) to understand how relevant stakeholders (participants) experience anaesthetic and recovery room education and training. This interpretivist stance allowed for inquiry into a complex phenomenon within its natural context (Ihuah & Eaton, 2013:935-940).

A disadvantage of an interpretivist lens is that the research could be seen as subjective by nature and could be influenced by researcher bias (Bitzer, 2018:5). In the current study, the researcher acknowledged her background, beliefs and experiences in the research by describing her relationship to the research in section 4.3. She adopted a ‘bracketed’ stance (Creswell, 2009:8-9; Denzin & Lincoln, 2018:19; Mackenzie & Knipe, 2006:3).

Although the study was mostly of an interpretative nature, its methodology included elements of pragmatism. Pragmatism highlights the behaviour of the participants in conjunction with the beliefs underlying their behaviour and actions (Bitzer, 2018:14).

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